A nurse is caring for a client in the prenatal clinic who is at 7 weeks of gestation.
The client reports urinary frequency and asks the nurse if this will continue throughout her pregnancy. Which of the following responses by the nurse is appropriate?

Choice A rationale:

Tachycardia, or a fast heart rate, is not a common finding in severe preeclampsia. While some women with preeclampsia may experience a slight increase in heart rate, it is not typically a significant or defining feature of the condition. In fact, some women with severe preeclampsia may even experience a slightly decreased heart rate due to increased vagal tone.

Choice B rationale:
Hypotension, or low blood pressure, is also not a typical finding in severe preeclampsia. Blood pressure is often elevated in preeclampsia, and it is one of the key diagnostic criteria. Hypotension would be a concerning finding in a woman with preeclampsia, as it could indicate a serious complication such as placental abruption or HELLP syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet count).

Choice C rationale:
Polyuria, or excessive urination, is not a characteristic finding of severe preeclampsia. In fact, many women with preeclampsia experience oliguria, or decreased urine output, due to decreased kidney function. This is because preeclampsia can cause damage to the blood vessels in the kidneys, impairing their ability to filter blood and produce urine.

Choice D rationale:
Headache is a common and often severe symptom of severe preeclampsia. It is thought to be caused by increased pressure within the brain due to swelling and vasoconstriction of the blood vessels. Headaches in preeclampsia can be very intense and may be accompanied by other symptoms such as blurred vision, nausea, and vomiting. They are often a sign that the preeclampsia is worsening and that delivery may be necessary.

Rationale for Choice A:
Judgmental and shaming: The statement "You are so young. Are you sure you are ready for the responsibilities of a sexual relationship?" conveys judgment and may make the adolescent feel ashamed or embarrassed. This can create a barrier to open communication and discourage the teen from seeking further guidance.
Dismisses the teen's concerns: It does not directly address the teen's question about contraception, suggesting that her concerns are not valid or important.
Does not provide helpful information: It does not offer any guidance or education about contraception, leaving the teen without the information she needs to make informed decisions about her sexual health.

Rationale for Choice B:
Erects barriers to access: Requiring parental consent for an examination can delay or prevent the teen from obtaining contraception, even if she is legally allowed to do so without parental consent.
Discourages open communication: It may make the teen feel like she cannot trust the nurse or that her privacy will not be respected, leading her to withhold information or avoid seeking further help.

Rationale for Choice C:
Defers responsibility: It shifts the responsibility for providing contraception counseling to the doctor, potentially delaying the teen's access to information and services.
May not be necessary: A physical examination is not always required before prescribing contraception, and in some cases, a nurse practitioner or other qualified health professional can provide this service.

Rationale for Choice D:
Open and non-judgmental: It invites the teen to share information about her sexual activity without judgment or pressure. Gathers essential information: It allows the nurse to assess the teen's individual needs and preferences, which is crucial for recommending the most appropriate contraceptive method.
Promotes informed decision-making: It empowers the teen to make informed choices about her sexual health by providing her with accurate and comprehensive information about contraception.